Lactation NotePlease email sarah@nestinglactation.com with any follow up questions Date of Visit MM DD YYYY Visit Location Start of Visit Hour Minute Second AM PM End of Visit Hour Minute Second AM PM Patient Name * First Name Last Name Patient Language Email * Patient DOB MM DD YYYY Infant Name Infant DOB MM DD YYYY Birth Weight Lactation Consultant Pediatrician OB Name Chief Complaint Pre Feed Weight Post Feed Weight Latch Body aligned belly to belly Wide mouth Infant aligned nipple to nose Lips flanged Audible swallows Pain Free Corrections to Latch Recommendations Breastfeed 8-12 times in 24 hours Supplement infant after feeds they are still hungry Pump as outlined below Feed infant every 2-3 hours during the day Feed infant every 3-4 hours at night Nipple ointment as recommended Other Teaching CDC rule of 4's for breast milk storage (4 hours at room temperature, 4 days in the fridge, 6 months in the freezer (12 months if fresh at 0°F) Breast pump instructions Nipple shield use Warning signs for Infant Warning signs for Parent Paced bottle feeding at an inclined side lying position 5 S's (shush, side lying, sway, suck, swaddle) Infant formula storage rules Other Follow Up Follow up recommended Follow up scheduled Follow up phone call recommended Follow up phone call scheduled Outside referral made (see below) Other Plan Education Resources Thank you!